How did we get here, where a boy dies sniffing inhalants to cure his hunger?

A boy in the Northern Territory has died “as a direct result of sniffing” the inhalants that helped alleviate his hunger, the royal commission into the protection and detention of children in the Northern Territory has heard.

He was “genial” child who frequented Bushmob – an organisation dedicated to helping youth at risk in indigenous communities.

“He told Bushmob he sniffed because he was not fed and it stopped his hunger. He said he did not want to be with his mother because she did not feed him and she drank alcohol. He was in clothing donated from another youth service.”

The boy slipped between Bushmob and other community services, his habit of sniffing and running away made it difficult for these services to provide him a permanent place to land.

He was known to the Department of Children and Families (DCF) because he was found handling hazardous substances – there were a total of five reports to DCF and the police about his inhalant use.

He was known to the justice department and the Department of Corrections because he was found stealing food from the supermarket.

On every occasion that the boy was sent to Bushmob, Bushmob also notified the government agency. “DCF did not provide feed back to Bushmob in relation to these notifications. On one occasion DCF asked Bushmob not to contact them as the child was not their client.”

A boy starving, sick, and regularly sniffing inhalants because the high helped him forget his hunger pains, and still, there was no one there to catch him…

“The child was not their client.”

Instead, the boy was found unresponsive on the warm bitumen of an Alice Springs carpark and died in hospital soon after.

This happened in Australia. Our Australia.

“It is understood the coroner’s report determined the child died as a direct result of sniffing inhalants,” the Bushmob submission reads.

“In Bushmob’s view the death of this child could have been prevented. There were multiple points at which his circumstances could have been investigated by DCF and action taken.”

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That is, Department of Children and Families could have stepped in when his inhalant use was first reported, instead of waiting for him to commit an offence.

They could have stepped in when they learned the boy's mother was failing to care for him - Bushmob says an Aboriginal family placement could have been identified, and support offered to both the boy and his mother.

They could have stepped in when they received reports of physical and medical neglect.

The boy's story is one of several case studies in a 36-page document submitted to the commission by Bushmob. They all show a desperate march towards a preventable death in people who were "ineffectually managed" by the Northern Territory government between August 2014 and August 2016.

There "is a significant cohort of young people aged 12-24 in the Northern Territory who are at high risk", the submission reads. And it's clear the system is letting these young people down.

According to Bushmob, there's no single point of accountability within the Northern Territory government for keeping young people safe. The lives of those at high-risk do not stop with one department or one officer. Instead they are passed between departments and onto services such as Bushmob, allowing "government agencies to abrogate responsibility".

Bushmob's recommendation is that the government establish a "single point of administration for high-risk young people".

There needs to be more funding, more consistently. At the moment, Bushmob is funded by the health department and the federal Indigenous advancement strategy. No money comes from the DCF, its main referrer. And - in cases such as the boy above - there is no additional funding provided to help services such as Bushmob protect someone at such high risk.

Reforms in the justice and health systems are also necessary, with children referred from the Department of Corrections having had "no examination into their early childhood experiences, their problems, their educational or health needs".

As the royal commission is preparing its final report, after 10-months of public hearings and various submissions, it is clear the system needs to change fundamentally. Yes, it's easy to say a more holistic, thorough, accountable system must be implemented. Obviously, the actual implementation will prove much more difficult.

But one thing is certain: The death of a starving boy to poisonous inhalants cannot be something that's a direct result of political inaction. Not here in Australia, not anywhere.

This boy, and many more like him, should have had a chance at life. Instead, he fell through the cracks and onto the bitumen of an Alice Springs carpark.